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Food Stamp Benefits

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					STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY                           DEPARTMENT OF SOCIAL SERVICES




                                              Application For



                                          Food Stamp Benefits
  Providing Nutritional
  Assistance to All Ages


                                       Follow these simple steps to apply for food stamp benefits.
                                       Note: If you have a disability or need help completing this
                                       application, please let a worker know and someone will help
                                       you.

                                       Step 1: Fill out as much of this application as you can, sign on
                                       page 1, and return it to the local food stamp office. We need at
                                       least your name, address and signature. If you are without
                                       money for food, you may be able to get emergency food
                                       stamp benefits in three (3) days.You need to answer all
                                       checked (✔) questions on all pages.

                                       Step 2: You will be scheduled for an interview with a food
                                       stamp worker who will go over this application with you and will
                                       ask you more questions to complete the application process.

                                       Step 3: You must bring proof of identification and income to your
                                       interview. You should bring other items as well, such as rent
                                       receipts, utility bills, or paycheck stubs. If you do not report and
                                       provide proof of expenses, no deduction from your income will
                                       be allowed for those expenses.

    Important Information for Immigrants

   ➤ You can apply for and get food stamp benefits for eligible family members, even if
           your family includes other members who are not eligible because of immigration
           status. For example, immigrant parents may apply for food stamp benefits for their
           U.S. citizen or qualified immigrant children, even though the parents may not be
           eligible for benefits.
   ➤       You do not have to provide immigration status information, social security numbers,
           or documents for any family members who are not eligible for food stamp benefits
           because of immigration status and who are not asking for food stamp benefits.
   ➤       Using food stamp benefits will not affect your immigration status or the immigration
           status of your family. Immigration information is private and confidential.
DFA 285 A1 (4/09)
 Applying For Food Stamp Benefits

Useful Tips and Information
Please read the following—there is nothing to fill out on this page.


 WHAT WE MEAN WHEN WE SAY
 To help you understand some of the words used in the application and the interview, refer to the definitions below.
  You, Anyone, Everyone — Any and all persons who live in                    Income — Money received or expected to receive this month,
  your home and who are applying for food stamp benefits.                    such as:
  When we need information about the other people in your                      •   Earnings, welfare, child support, SSI or Social Security, or
  home, we will ask you.                                                           veterans payments
  Your Household — People living in the home who buy and                       •   Pension or retirement payments
  prepare food together and are applying for food stamp
  benefits.                                                                    •   Unemployment (UIB), State Disability (SDI) or other
                                                                                   disability
  Food Stamp Benefits — Benefits for low-income households
  to help buy food.                                                            •   Strike funds, payments from roomers, school grants and
                                                                                   loans
  Food Stamps Expedited Service — Food stamp benefits
  available to you within three (3) days.                                      •   Cash gifts, cash winnings, or any other cash payments
  Resources — Money you have, such as:                                       Cash Aid — California Work Opportunity and Responsibility to
      •   Cash on hand, uncashed checks, money in checking                   Kids (CalWORKs), Refugee Assistance, or your county’s local
          accounts, savings accounts, or savings certificates, etc.          Cash Aid program [General Assistance or General Relief
      •   Trust deeds, notes receivable, stocks or bonds, etc.               (GA/GR), or Cash Assistance Program for Immigrants (CAPI)].
  Utilities — Gas, electricity, heating, fuel, telephone (basic rate),
  utility installation, garbage and trash pickup, water, sewage, etc.

             OTHER THINGS YOU SHOULD KNOW                                           COMPLAINTS AND STATE HEARINGS

  • You may wonder why we ask some of the questions. All                      If you have a complaint, try to work it out with the
     questions are required by Federal/State law to determine                 county. If you can’t work it out, you may call or write to:
     your eligibility for food stamp benefits.                                           California Department of Social Services
  • You can apply for food stamp benefits and cash aid at the same                                744 P Street, MS 8-16-50
     time and have only one interview for both, except when you                                    Sacramento, CA 95814
     apply for GA/GR as a cash aid.                                                           Phone Number: 1-800-952-5253,
                                                                                         or for the hearing or speech impaired call
  • If your food stamp benefits, Authorization Document (AD) or                                       1-800-952-8349
     issuance cards are lost in the mail, you must report it before the
     end of the month in which you should have gotten them. But if            If you think any action taken by the County is wrong, you
     they were stolen or destroyed, you must report your loss within          can ask for a State Hearing by writing to your local
     ten (10) days of the incident.                                           county welfare office or by calling the phone numbers
                                                                              listed above. You must ask for a hearing within ninety (90)
  • If you receive too many food stamp benefits, you will have to pay         days of the action and tell why you want one.
     them back and/or your benefits may be lowered or stopped. Your
     Social Security Number (SSN) may be used to collect the amount           The law says that all applicants/recipients for aid,
     of benefits owed, through the courts, other collection agencies          benefits or services are to be treated fairly without
     and for federal government collection action.                            regard to race, color, national origin, political affiliation,
                                                                              religion, marital status, sex, age or disability.
  • Your SSN will be used to check identity to prevent duplicate              If you think you have been discriminated against, you
     participation and to verify eligibility and benefits. The SSN will be
                                                                              may file a complaint by:
     used in computer matches to check your income and resources
     with records from tax, welfare, employment, the Social Security          1. Contacting your county’s civil rights coordinator; or
     Administration and other agencies. Differences may be checked            2. Writing to or calling:
     out with you and with employers, banks, or others. Fraudulent                   The state’s Civil Rights Bureau, M.S. 8-16-70,
     participation in the Food Stamp Program may result in criminal or               P.O. Box 944243, Sacramento, CA 94244-2430
     civil action or administrative claims.                                          1-866-741-6241 (Toll Free)
  • Providing your SSN is not required when you first submit your             3.Or for Food Stamp benefits only, writing to:
     application. However, you will be asked to give us information to               Secretary of Agriculture
     figure the eligibility and benefits for other members of your                   U.S. Department of Agriculture
     household.You usually have to give us your SSN(s) or proof of                   14th & Independence Avenue, S.W.
     application for your SSN(s) before we can give you any benefits.                Room 200A
     We can deny you or any member of your household benefits for                    Administration Building
     failure to provide an SSN.                                                      Washington, D.C. 20250

DFA 285 A1 (4/09)
Application for Food Stamp Benefits
   Applicant Information
✔ 1. Please fill out the following personal information for the person requesting food stamp benefits.

   Name (Last, First, Middle)

   Telephone Number (include area code)

   Home Address (Street , P.O Box, Apt. #)

   City, State, Zip Code

   Mailing address (if different from above)

   City, State, Zip Code

2. The food stamp office can provide an interpreter at no cost to you. Would you like an
   interpreter at your interview? ■ Yes ■ No If “Yes,” what language? ___________________
3. To help us improve our services to you, please complete A, B, and C below. Check all that apply to
   you. The law says we must record your ethnic group, race, and language. If you do not complete these
   items, the county will do it for you. This will not affect your eligibility.
     A. ETHNICITY (Everyone must also answer B)
        Are you Hispanic or Latino?           ■ Yes ■ No
     B. RACE/ETHNIC ORIGIN - Check all boxes that apply to you. If you do not complete
        these items, the county will do it for you. This will not affect your eligibility.
        ■ American Indian or Alaskan Native
        ■ Black or African American
        ■ Asian (If checked, please select one or more of the following)
           ■ Filipino        ■ Chinese            ■ Japanese         ■ Cambodian         ■ Korean
           ■ Vietnamese ■ Asian Indian ■ Laotian                     ■ Other Asian (specify)_______________
        ■ Native Hawaiian or Other Pacific Islander (If checked, please select one or more of the following)
           ■ Native Hawaiian ■ Guamanian ■ Samoan ■ Other(specify)____________________
        ■ White
     C. PRIMARY LANGUAGE:
        ■ English         ■ Spanish           ■ Lao               ■ Tagalog ■ American Sign
        ■ Cantonese ■ Cambodian ■ Vietnamese ■ Russian ■ Other(specify)___________
✔ 4. Someone in the household is: (check more than one if applicable)
        ■ Disabled                          ■ Homeless
        ■ Elderly (60 & older)              ■ Migrant/ Seasonal Farmworker –
        ■ Without money for food               Has your only income stopped? ■ Yes ■ No
  5. Do you have a physical or mental condition that requires special help during
      your interview with a food stamp worker? ■ Yes ■ No
✔ 6. How much is your rent or mortgage this month? $_____________________
✔ 7. How much are your utilities this month, if separate from your rent or mortgage? $____________
 I have been informed about getting emergency food stamp benefits within three (3) days.


   Signature                                                          Date


 County Use Only:

 Case Name ________________________________________ Case # __________________________
 Application Type:     ■ New          ■ Recert   Date received by County _________________
 Screened for Expedited Service (ES)?   ■ Yes ■ No        ES Eligible ■ Yes ■ No
DFA 285 A1 (4/09) REQUIRED FORM – NO SUBSTITUTES PERMITTED                                      page 1 of 3
Application for Food Stamp Benefits

   Household Information
8. Complete the following information for all persons in the home, including yourself. The County
   will use this information to determine eligibility only.

                                                                          Relationship                                Do you buy and
                                                       Social Security    (i.e. son, wife,                            prepare food
 Name                                                  Number (If none,   friend , foster                             with this person?
 (Last, First, Middle)                                 write none)        child, etc.)     Circle one Date of Birth   (Circle one)
                                                                                         Male                           Yes / No
  1.                                                                                            Female

                                                                                         Male                           Yes / No
  2.                                                                                            Female

                                                                                         Male
                                                                                                Female
                                                                                                                        Yes / No
  3.
                                                                                         Male                           Yes / No
  4.                                                                                            Female

                                                                                         Male                           Yes / No
  5.                                                                                            Female

                                                                                         Male                           Yes / No
  6.                                                                                            Female

                                                                                         Male                           Yes / No
  7.                                                                                            Female

                                                                                         Male                           Yes / No
  8.                                                                                            Female

                                                                                         Male                           Yes / No
  9.                                                                                            Female


10.                                                                                      Male
                                                                                                Female
                                                                                                                        Yes / No




   Income and Employment
✔ 9. Do you have or will you receive any income this month?                                ■ Yes         ■ No
     List all your household income below:

 Name of person who gets money                                                                              How much each month?

                                                                                                            $

                                                                                                            $

                                                                                                            $

                                                                                                            $



   Resources
✔ 10. How much money do you have? This includes money in bank accounts, in your home, or any
      other place. $ ______________

 County Use Only:




DFA 285 A1 (4/09) REQUIRED FORM – NO SUBSTITUTES PERMITTED                                                                  page 2 of 3
Application for Food Stamp Benefits

   Important Information

    ➤ The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs
           and activities on the basis of race, color, sex, religion, national origin, or political beliefs.
           You may file a complaint if you think you have been discriminated against. If you
           disagree with the decision of the county, an appeal process is available to you.
    ➤      The information on this application may be shared with federal, state and local agencies
           only for the purposes of verifying eligibility for the Food Stamp Program. This process
           may include confirmation with the U.S. Citizenship and Immigration Services (USCIS)
           (formerly INS) of the immigration status only of those persons seeking food stamp
           benefits. Federal law says the USCIS cannot use the information for anything else except
           cases of fraud.


   Signature
   I certify under penalty of perjury under the laws of the United States of America and the
   State of California that the information I have provided on this application is true, correct
   and complete.



  Signature (Adult Household Member or Authorized Representative)            Date




  Signature of Witness or Interpreter                                        Date




  Signature of Eligibility Worker                                            Date




DFA 285 A1 (4/09) REQUIRED FORM – NO SUBSTITUTES PERMITTED                                           page 3 of 3

				
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Description: Food Stamp Benefits